Pekkari et al.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:48

http://www.sjtrem.com/content/22/1/48

ORIGINAL RESEARCH Open Access

Abdominal injuries in a low trauma volume

hospital - a descriptive study from northern
Sweden
Patrik Pekkari1, Per-Olof Bylund2, Hans Lindgren3 and Mikael Öman2*

Abstract
Background: Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical
intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to
these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and
radiologic findings, and delay definite treatment. Here, we determined the incidence, diagnosis, and treatment of
traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative
management of patients with these injuries in a low trauma volume hospital.
Methods: This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147
abdominal injuries from an isolated abdominal trauma (n = 70 patients) or during multiple trauma (n = 40 patients).
Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009.
Results: The median New Injury Severity Score was 9 (range: 1–57) for 147 abdominal injuries. Most patients
(94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with
CT < 60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ
injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was
performed for 28 patients, either immediately (n = 17) as result of operative management or later (n = 11), due to
non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple
abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly
more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days.
Conclusions: Non-operative management of patients with abdominal injuries, except for hollow viscus injuries,
was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these
patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma
laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of
trauma care at low trauma volume hospitals.
Keywords: Abdominal injuries, Low trauma volume hospital, Non-operative management

* Correspondence: mikael.oman@surgery.umu.se
2
Department of Surgical and Perioperative Sciences; Surgery, Umea University,
SE-901 85 Umea, Sweden
Full list of author information is available at the end of the article

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reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
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unless otherwise stated.
Pekkari et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:48
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Background
Patients with severe abdominal injuries after a blunt or
penetrating trauma appear infrequently in most hospitals
in Sweden. During the last few decades, management of
blunt abdominal injuries has changed from an aggressive
surgical approach to non-operative management (NOM),
because high quality computerized tomography scanning
(CT) provides the ability to readily recognize and follow
abdominal injuries [1,2]. Furthermore, advances in
catheter-based technologies have expanded the indications
for interventional radiology and facilitated transcutaneous
angiographic embolization (TAE). TAE is a widely accepted
adjunct in managing solid organ injuries with on-going
intra-abdominal or retroperitoneal haemorrhage [3,4]. How-
ever, as a result of these trends in abdominal trauma man-
agement, a growing proportion of surgeons at low trauma
volume hospitals do not gain sufficient experience in per-
forming trauma laparotomies. Due to the scarcity of these
injuries and the increasing lack of experience in open surgi-
cal procedures in low trauma volume hospitals, there is a
need to enhance the local dataset with defined epidemi-
ology, management strategies, and patient outcomes; this
enhancement will facilitate identification of potential haz-
ards in NOM. The aim of this study was to evaluate the in-
cidence, the mechanism of injury, the prehospital time
period, the diagnostic workup, and the application of ad-
equate treatment for abdominal injuries, to provide a basis
for identifying potential hazards in non-operative manage-
ment of traumatic abdominal injuries at our low trauma vol-
ume hospital.
Methods
The University Hospital of Umeå is a tertiary referral
centre for all of northern Sweden. It serves a population
of 880 000 inhabitants in the tertiary catchment area of
225 000 km2. This catchment area corresponds to the
area of the United Kingdom, with transferral distances
from 110 up to 600 kilometres. Because the hospital is
the only referral centre in the primary catchment area,
which has a population of 145 000 within an 80 km ra-
dius, 100% of patients with higher grade trauma are
referred.
A computerized trauma registry (Injury Database) of
patients primarily treated at the University Hospital of
Umeå, has been prospectively maintained since 1985.
For the present study, we retrospectively collected data
from the Injury Database regarding all patients with a
hospital admission from January 2000 to December 2009
for abdominal injuries, with or without injuries in other
body regions. Written informed consent was obtained
from all patients. The study was a clinical quality-control
study approved by the Head of the Department of Surgery,
Umeå University Hospital, Umeå, Sweden. The study fol-
lows the guidelines of the revised UN declaration of
Page 2 of 8
Helsinki in 1975 and its latest amendment in 2008 (6th
revision). Permission to use the Injury Database was
obtained from the County Council’s Research Injury
Database Committee. The study was performed at the
Umeå University Medical School, Umeå, Sweden. Pa-
tients without abdominal injuries from the primary
catchment area, or referred patients with or without
abdominal injuries primarily resuscitated at the local
hospital in the secondary or tertiary catchment area,
were not included in the study. These two groups of
patients with AIS3+ injuries constituted about 230 pa-
tients annually during the audit period.
Time logs from the prehospital response, emergency
unit, department of radiology, and surgery were used to
evaluate the efficiency of prehospital and in-hospital
trauma care. Patient characteristics included age, gender,
mechanism of injury, diagnostic methods, radiologic
examination, surgical interventions, and length of hos-
pital stay, including time spent in the intensive care unit
(ICU).
Injury severity was classified according to the Injury
Scaling and Scoring System [5] and the Abbreviated In-
jury Scale (AIS) 2005 [6], which appraises the risk of
death. The AIS range is 1–6, where AIS1 = minor, AIS2 =
moderate, AIS3 = serious, and AIS4-6 = severe, critical,
and maximal injuries. AIS grading was completed and
coded by licensed AIS specialists. The New Injury Severity
Score (NISS) calculates the sum of squares of the top
three AIS scores, regardless of body region, providing a
score of 0 – 75. Patients with NISS > 15 are classified as
seriously injured. NISS is regarded appropriate for patients
with multiple injuries within the same anatomic region
[7], which describes the patients in our study. A patient
with multiple trauma was defined as having injuries in
two or more different anatomic sites; a patient with an iso-
lated abdominal trauma had injuries confined to the ab-
dominal cavity or retroperitoneal space.
Descriptive data are expressed in terms of the number
(percent) or median (range). Calculations were performed
with SPSS 21.0.0.0 (SPSS Inc. Chicago, IL, USA) and
Minitab® 16.1.0 (Informer Technologies Inc., http://
minitab.software.informer.com). Fisher’s exact test was
used to compare proportions between groups, and a p-
value less than 0.05 was considered statistically significant.
Results
Over the ten year period of 2000–2009, we identified
110 patients (n = 75 men) with traumatic abdominal in-
juries that were primarily treated as in-patients at our
hospital. The median age was 21 (6–88) years; 42 pa-
tients were <18 years old, 58 patients were 18–65 years
old, and 10 patients were >65 years old. Seventy patients
experienced isolated abdominal trauma and 40 patients
experienced multiple trauma; 87 patients had a single
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abdominal injury (SAI) and 23 patients had multiple ab- Diagnostics

dominal injuries (MAI). There were significantly more
SAI in patients with isolated abdominal trauma than in
those with multiple trauma (p < 0.05), and patients
with MAI had NISS > 15 more frequently than NISS <
15 (p < 0.05). The mechanism of injury was blunt
trauma in 103 patients (94%), and penetrating trauma in
seven patients (six stab wounds and one gunshot wound).
Nearly 50% of patients were injured in vehicle-related
crashes (Table 1).
Prehospital emergency care
Prehospital response was provided for 56 patients; the
response team arrived at the scene in < 15 min (median:
12 min; range: 5–49) for 34 (61%) patients. Prehospital
response was significantly more often activated for pa-
tients with multiple trauma compared to those with iso-
lated abdominal trauma (p < 0.05). The time spent at the
scene was < 15 min (median: 13 min; range: 5–36) for 36
patients (64%). The time from the alert to the arrival at
the emergency room (ER), was < 60 min (median: 45 min;
range: 8–141) for 42 patients (75%) (Table 2). Of the 33
patients injured in vehicle crashes, 15 received prehospital
care at the scene for > 15 min. Among the 56 patients with
a prehospital response, 55% had NISS scores >15; in con-
trast 19% of patients that arrived to the hospital by private
car or taxi (n = 54) had NISS scores >15.
A total of 103 patients (94%) with multiple or isolated
abdominal trauma were initially diagnosed with a CT
after 67 (range: 9–1277) and 114 (range: 17–1153) min
in the ER, respectively. Of 37 patients with multiple
trauma and 66 patients with isolated abdominal trauma,
15 (41%) and 10 (15%), respectively, were examined with
CT within 60 min from arrival at the ER. The time from
ER arrival to the start of a CT examination was signifi-
cantly shorter among patients with multiple trauma than
among those with isolated abdominal trauma (p < 0.05)
(Table 2). Seven patients were judged to require immedi-
ate surgery and went directly to the operating room
(OR) without radiologic examination, except for an
anterior-posterior chest and pelvis X-ray in the ER.
These patients either had penetrating injuries and/or
showed signs of abdominal injury with circulatory in-
stability, despite fluid resuscitation. Two patients in this
group underwent a positive diagnostic peritoneal lavage
in the ER; one patient with a penetrating perineal injury,
but stable circulation, underwent a sigmoidoscopy prior
to surgery.
Injuries and treatment
Among all 110 patients, 147 abdominal organ AIS1+ injuries
were found. In addition, there were 109 extra-abdominal in-
juries in the multiple trauma group, which resulted in a total

Table 1 Characteristics of 110 patients with multiple trauma or isolated abdominal trauma
Multiple trauma Isolated abdominal trauma All trauma Patients
Patients MAI SAI MAI SAI MAI SAI Total
Male (n) 10 15 6 44 16 59 75
Female (n) 5 10 2 18 7 28 35
Male age in year (range) 35 (16–71) 30 (8–71) 19 (12–48) 21 (8–81) 27 (12–71) 21 (8–81) 22 (8–81)
Female age in year (range) 48 (12–72) 16 (11–88) 49 (36–62) 14 (6–84) 48 (12–72) 14 (6–88) 15 (6–88)
Mechanism (n) MAI SAI MAI SAI MAI SAI Total
Blunt 13* 25* 6* 59* 19 84 103
Penetrating 2 0 2 3 4 3 7
Severity MAI SAI MAI SAI MAI SAI Total
NISS > 15 (n) 12 11 5 13 17* 24* 41
NISS < 15 (n) 3 14 3 49 6* 63* 69
NISS (range) 27 (12–57) 14 (1–43) 20 (8–36) 4 (1–18) 27 (8–57) 18 (1–43) 9 (1–57)
Circumstance (n) MAI SAI MAI SAI MAI SAI Total
Vehicle related 7 18 4 25 11 43 54
Fall 5 6 1 19 6 25 31
Assault 2 0 1 6 3 6 9
Other 1 1 2 12 3 13 16
Legends: n = number of patients. MAI = Multiple abdominal injury. SAI = Single abdominal injury. Age in median (range). NISS = New Injury Severity Score. NISS in
median (range). * = p < 0.05.
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Table 2 Prehospital response, time and treatment in 110 patients with multiple trauma or isolated abdominal trauma
Multiple trauma Isolated abdominal trauma All trauma Patients
Response MAI SAI MAI SAI MAI SAI TOTAL
PR No 1* 6* 2* 45* 3 51 54
PR Yes 14* 19* 6* 17* 20 36 56
CT No 2 1 2 2 4 3 7
CT Yes 13 24 6 60 19 84 103
RT <15 9 10 3 12 12 22 34
TOS <15 8 12 3 13 11 25 36
TER <60 12 13 5 12 17 25 42
TCT <60 7 8 1 9 8 17 25
Time MAI SAI MAI SAI MAI SAI TOTAL
RT 10 (5–49) 13 (5–37) 14 (5–16) 10 (5–40) 12 (5–49) 12 (5–40) 12 (5–49)
TOS 14 (5–34) 13 (5–36) 15 (5–20) 7 (5–20) 14 (5–34) 11 (5–36) 13 (5–36)
TER 42 (17–141) 48 (12–85) 42 (15–69) 38 (8–100) 42 (15–141) 45 (8–100) 45 (8–141)
TCT 43* (28–110) 71* (9–1277) 92* (57–1035) 115* (17–1153) 74 (28–1035) 98 (9–1277) 94 (9–1277)
Patients MAI SAI MAI SAI MAI SAI TOTAL
OM 5 4 3 5 8 9 17
NOM-S 7 19 3 53 10* 72* 82
NOM-F 3 2 2 4 5* 6* 11
Total 15 25 8 62 23 87 110
Legends: MAI = Multiple abdominal injury. SAI = Single abdominal injury. PR = Prehospital Response. Time in minutes. < 15 = less than 15 minutes. < 60 = less than
minutes. TOS = Time on scene. CT = Computerized tomography. RT = Response time denotes time from alert to arrival at scene. TER = Time to ER denotes time
from alert to arrival at the emergency room, i.e. total prehospital time. OM = Operative Management. NOM-S = Non Operative Management Success. NOM-F = Non
Operative Management Failure. TCT = Time to CT denotes time from arrival at ER to start of CT examination. Time in median (range). * = p < 0.05.

median NISS of 9 (range: 1–57). In patients with multiple
and isolated abdominal trauma, 23 (58%) and 40 (57%) had
abdominal AIS3+ injuries, respectively; thus, the NISS was
>15 in 58% and 26%, respectively. In patients with multiple
and isolated abdominal trauma, MAI were found in 38%
and 11%, respectively. Patients with isolated abdominal
trauma had substantially more SAI than MAI (Table 1).
Seventeen patients received primary operative manage-
ment. NOM was initiated in 93 patients (85%), but failed in
eleven patients. Among the latter, six had hollow viscus in-
juries, four had on-going haemorrhages from solid organ in-
juries, and one had a pancreatic duct disruption (Table 3).
There was no difference in the numbers of successful
and failed NOM between patients injured in multiple or
isolated abdominal trauma, but there were significantly
more failures than successes in patients with MAI com-
pared to those with SAI (p < 0.05) (Table 2).
Solid organ injuries
Solid organ injuries comprised 78% of all injuries. The or-
gans most frequently injured were the kidneys (n = 39),
the liver (n = 34), the spleen (n = 31), the small intestine
(n = 9), and the mesenteric vessels (n = 7). The NOM was
95% successful among patients with solid organ injuries.
NOM was even initiated in 15 patients with solid organ
AIS4+ injuries (7 kidney, 5 liver, and 3 spleen injuries); of
these, two failed (1 spleen and 1 liver injury) (Table 3).
Spleen injuries were found in 31 patients. Splenectomy
was performed in two patients (AIS3 and AIS5 injuries) as
part of damage control surgery, and it was performed in
three patients (AIS2, AIS3, and AIS4 injuries) due to
NOM failure. Twenty-six patients with spleen injuries had
successful NOM, but one of these, with an AIS3 injury
and on-going haemorrhage, underwent an adjunct TAE.
Liver injuries were found in 34 patients. Open packing of
the liver as part of damage control surgery was performed
in two patients (AIS4 and AIS5 injuries); of which one had
a successful postoperative TAE. One patient (AIS5 injury)
failed NOM. Successful NOM were achieved in 31 pa-
tients; of these, one (AIS4 injury) underwent endoscopic
retrograde cholangiopancreatography with sphincterotomy
at 14 days after the injury, and a trans-sphincteric endo-
prosthesis was placed, due to bile leakage.
All 39 kidney injuries were successfully treated with
NOM. One patient (AIS4 injury) with persistent haem-
orrhage underwent TAE as an adjunct to NOM.
Of two patients with pancreatic trauma, one patient,
with an AIS3 injury, underwent laparotomy and distal
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Table 3 Operative and non-operative management of 110 patients were subjected to surgery within three hours of
patients with 147 abdominal injuries in AIS grade their arrival to the ER, due to one or several of the fol-
AIS grade NOM NOM-F OM Total lowing: penetrating injury (n = 2), circulatory instability
≤2/≥3 ≤2/≥3 ≤2/≥3 ≤2/≥3 with signs of abdominal injury (n = 5), peritonitis (n = 3),
Solid organ injury (n = 115) and/or free intra-peritoneal air detected on radiologic
Kidney (n = 39) 22/17 0 0 22/17
examination (n = 2). Six patients that received an initial
CT with no abnormal findings and no clinical signs or
Liver (n = 34) 21/10 0/1 0/2 21/13
symptoms of abdominal injury, failed NOM. These pa-
Spleen (n = 31) 15/11 1/2 0/2 16/15 tients underwent exploratory laparotomy after 7–60 h of
Adrenal gland (n = 9) 8/1 0 0 8/1 observation in the ICU or surgical ward. They were
Pancreas (n = 2) 1/0 0/1 0/0 1/1 taken to the OR, either after deterioration in their clin-
Hollow viscus injury (n = 17) ical condition with peritonitis (n = 5) and/or haemo-
Small intestine (n = 9) 0 1/3 1/4 2/7
dynamic instability (n = 2), and/or after a follow-up CT
had revealed free intra-peritoneal air (n = 3). The initial
Colon (n = 5) 0 1/1 1/2 2/3
CT disclosed intraperitoneal bladder injuries in two pa-
Bladder (n = 2) 0 0 0/2 0/2 tients; these underwent surgery 3 and 6 h after arrival to
Rectum (n = 1) 0 0 0/1 0/1 the ER (Table 4). No patients with injuries to hollow or-
Other injury (n = 15) gans or to mesenteric vessels were successfully treated
Abdominal wall (n = 7) 3/0 0 4/0 7/0 with NOM.
Diaphragm (n = 1) 0 0 0/1 0/1
Abdominal vessel (n = 7) 0 0 2/5 2/5 Other injuries
All injuries (n = 147) One patient underwent a combined abdominal and thor-
Total 70/39 3/8 8/19 81/66 acic surgical procedure, due to a penetrating injury
Legends: Time to surgery denotes time in hours from arrival at the emergency across the diaphragm, that caused both liver and lung
room to beginning of surgical procedure. AIS = Abbreviated Injury Scale. injuries. Four patients underwent operative manage-
ment; three were due to penetrating abdominal wall in-
juries, without coexisting intra-abdominal injuries; and
pancreatectomy, due to distal transection of the pancre- one was due to an abdominal wall defect after blunt
atic duct. The other patient, with an AIS2 pancreatic in- trauma.
jury, was treated successfully with NOM.
Length of hospital stay
Hollow viscus injuries and injuries to mesenteric vessels Patients that experienced isolated abdominal trauma (n = 70)
A total of 14 patients with single or multiple intestinal stayed in the hospital for 5 days (range: 1–28 days). Of these,
injuries and/or mesenteric vascular injuries were treated 21 were admitted to the ICU for 1 day (range: 1–6 days). Pa-
at the hospital during the study period. Of these, eight tients that experienced multiple trauma (n = 40) stayed in

Table 4 Surgical procedures in 28 patients with 35 abdominal injuries in time intervals and AIS grade
Time to surgery (hours) <1 1-3 4-6 7-12 13-24 25-48 >48 Total
AIS grade ≤2/≥3 ≤2/≥3 ≤2/≥3 ≤2/≥3 ≤2/≥3 ≤2/≥3 ≤2/≥3 ≤2/≥3
Vascular repair 1/1 1/1
Splenectomy 0/2 1/0 0/1 0/1 1/4
Liver packing* 0/1 0/1 0/1 0/3
Distal pancreatectomy 0/1 0/1
Bowel repair/resection 0/3 0/3 0/1 0/2 1/1 1/0 2/10
Enterostomy 0/2 1/0 0/1 1/0 2/3
Bladder repair 0/1 0/1 0/2
Diaphragm repair 0/1 0/1
#
Abdominal wall repair 1/0 1/0 1/0 1/0 4/0
TOTAL 7 9 3 4 5 3 4 35
Legends: Time to surgery denotes time in hours from arrival at the emergency room to beginning of surgical procedure. AIS = Abbreviated Injury Scale. *Liver
packing as part of damage control surgery. # Two patients underwent abdominal wall repair without laparotomy.
Pekkari et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:48
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the hospital for 8 days (range: 1–36 days). Of these,
29 were treated in the ICU for 3 days (range: 1–32 days).
Mortality
One patient experienced multiple trauma and presented
at the ER in profound haemorrhagic shock, due to ex-
tensive abdominal and pelvic crush injuries (NISS = 57).
This patient died of exsanguination 12 h after arrival,
despite immediate surgery. The surgical procedures in-
cluded subdiaphragmatic clamping of the aorta, suturing
several large lacerations of the inferior vena cava, pelvic
packing, and external fixation of the pelvis.
Discussion
Our study confirmed that our hospital had a low incidence
of patients with abdominal injuries that required surgical
intervention. During the study period, around ten patients
annually from the primary catchment area of the University
Hospital of Umeå were treated for AIS1+ abdominal injur-
ies. The median age was 21 (6–88) years, and the majority
of the patients were men (68%). Most patients had been in-
jured in an isolated abdominal trauma (n = 70), which in
most cases (79%), caused a single abdominal injury. Nearly
50% of patients were injured in a vehicle-related trauma,
and only seven patients (6%) had a penetrating trauma. We
have only found a few studies from Scandinavia that de-
scribed the local incidence and management of abdominal
injuries in the adult and paediatric population [8-11]. Those
studies showed that the male gender was overrepresented
and that penetrating injuries were relatively rare, consist-
ent with our findings. A recent two-year review from the
Swedish National Trauma Registry that comprised 7200
patients that experienced trauma (median age 38 years),
with or without abdominal injuries, reported that men
comprised 66.7% of the injured, that more than 50% were
injured in vehicle crashes, and that only 6.4% had pene-
trating injuries [12]. The median age of patients with ab-
dominal injuries in our study was lower than that of the
general population of Swedish patients that experienced
trauma. Thus, abdominal injuries appeared to affect youn-
ger patients rather than older patients, and they often re-
sult from an isolated abdominal trauma.
Our study showed that most patients with NISS > 15
arrived at the ER by ambulance or helicopter, and nearly
20% of these patients with severe injuries arrived by pri-
vate car or taxi. In comparing our study to national
Swedish data [12], the prehospital response time was 12
vs. 13 min, the time on scene of was 13 vs. 18 min, and
the time from the alert to arrival at the ER was 45 vs.
52 min, respectively. From our perspective, these times
were reasonable, given the vast primary catchment area.
Among the patients injured in motor vehicle crashes
(n = 24), 50% were treated at the scene longer than
15 min, due to prolonged extrication from vehicles.
Page 6 of 8
Seven of 110 patients with abdominal injuries were
judged to require immediate surgical intervention, and
they were sent to the OR before receiving a CT. Two of
these patients underwent a positive diagnostic peritoneal
lavage prior to surgery to determine the presence of hae-
moperitoneum. The ‘Focused Assessment with Sonog-
raphy in Trauma’ (FAST) approach was not in clinical
practice at our hospital during the study period. The
remaining 103 patients had stable circulation in the ER
and underwent CT in accordance with Advanced Trauma
Life Support Guidelines [13]. Ten additional patients were
taken to the OR for abdominal surgery shortly after the
CT examination.
We found that, for patients with multiple trauma and
isolated abdominal trauma, the times between arrival to
the ER and the CT examination were 67 and 114 min,
and 41% and 15%, respectively, were examined within
60 min. The national data reported the time from the
ER to the CT [12] was 48 min, but that estimate ex-
cluded patients with times exceeding 200 min. Despite
this difference, our prolonged times may reflect a time-
consuming element in the initial trauma management
that may potentially be improved at our hospital.
In the last two decades, incorporating NOM into solid
organ injury treatments was one of the most notable
changes in the care for patients after blunt abdominal
trauma. NOM of solitary liver, spleen, and renal injuries
is considered the standard of care in all injured adults
that are haemodynamically stable, without signs of peri-
tonitis. Numerous studies have demonstrated NOM suc-
cess rates in adult patients that exceeded 80% in spleen,
90% in liver, and 90% in renal injuries [1,14-21]. NOM
has also been successful in paediatric patients [22]. Even
multiple trauma patients with more than one solid organ
injury can be treated with NOM, provided that the pa-
tient is haemodynamically stable and carefully moni-
tored, with no signs of peritonitis [2,23]. In this study,
we found significantly more NOM failures than suc-
cesses among patients with more than one abdominal
injury; this finding suggests that patients with MAI
should be followed more cautiously when treated with
NOM. We found no difference in NOM success and
failure rates between patients that experienced multiple
or isolated abdominal trauma. The overall NOM success
rate was 89%. The NOM failures comprised six patients
with delayed diagnoses of hollow viscus perforation, one
patient with pancreatic duct disruption, and four pa-
tients with persistent solid organ injury haemorrhage.
The NOM success rate was 95% among patients with
kidney, liver, and spleen injuries; even those with AIS4+
injuries had a 86% NOM success rate. Only three pa-
tients with on-going solid organ injury haemorrhage
underwent TAE as an adjunct to NOM or surgery. In fu-
ture, with increasing indications and accessibility to
Pekkari et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:48
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interventional radiology, more patients will be offered
treatment with this minimally-invasive technique.
Pancreatic trauma is a special case, because it is a rare
injury, and diagnosis requires a high degree of suspicion.
NOM in pancreatic trauma remains limited to injuries
without ductal disruption, which requires surgery or ad-
vanced endoscopy [1,24,25]. We found only two pancre-
atic injuries, and both initially received NOM. NOM
failed for one, and after seven hours of observation, distal
pancreatectomy was performed, due to ductal disruption.
Early diagnosis of hollow viscus injury may be difficult,
because the symptoms are minute and the initial CT in-
dications are subtle [26,27]. In this study, the diagnosis
and surgical management of intestinal perforation was
delayed by 7–60 h in 6 of 14 patients.
Among patients that experienced trauma from the pri-
mary catchment area of the University Hospital of
Umeå, only 2–3 patients, annually, required abdominal
surgery. These findings were consistent with a study
from Linköping University Hospital, which serves a local
population of 260 000, and it serves 835 000 people as a
secondary and tertiary referral centre; they found only
five patients with trauma required laparotomy over one
audit year [11]. At Ullevaal University Hospital in Oslo,
the largest trauma centre in Norway, which serves about
2.5 million people, an average trauma team leader partic-
ipated in ten trauma laparotomies per year [10]. Sur-
geons that work at low trauma volume hospitals should
be enrolled in educational programmes for open surgical
procedures and take part in exchange programmes with
centres that have high trauma workloads, to ensure the
quality of operative trauma care. Technical surgical training
simulations have mainly focused on highly technique-
dependent, mini-invasive, endoscopic, laparoscopic, percu-
taneous, or endovascular procedures. There is a scarcity of
studies that evaluate models for open surgical simulation,
including synthetic prototypes, animal models, or human
cadavers, compared to models with a mini-invasive ap-
proach. Two recent reviews [28,29] emphasized the need
for more studies on simulation-based teaching techniques
to provide data for evaluating how well these models can
replace or enhance the traditional surgical training through
apprenticeship in the operating theatre.
Limitations
The low total number of patients and small subgroups
in this study limited the feasibility of further statistical
analysis. In this register study, it was not possible to ana-
lyse the long-term effects of the timing of operative
management or NOM failure.
Conclusions
Surgeons exposed to few abdominal traumas achieve
limited experience in the diagnostics and treatment of
Page 7 of 8
these injuries. Despite the low incidence of abdominal
trauma at our hospital, NOM was successful in 89% of
all injuries and in 95% of solid organ injuries. Surgeons
working in a low volume trauma hospital like ours, con-
tinue to make the right decisions and determine whether
a patient should undergo an operative intervention. In
time, a new generation of surgeons that are subspecia-
lized and skilled in mini-invasive procedures, but with
limited experience in traditional open surgery, will ul-
timately be responsible for making these decisions. To
ensure local competence in performing trauma laparoto-
mies, quality assurance programmes should be imple-
mented to provide laboratory training courses and to
sponsor national and international trauma surgery ex-
change programmes.
Abbreviations
AIS: Abbreviated Injury Scale; CT: Computed tomography; ER: Emergency
room; ICU: Intensive care unit; MAI: Multiple abdominal injuries; NISS: New
Injury Severity Score; NOM: Non-operative management; OR: Operating
room; SAI: Single abdominal injury; TAE: Transcutaneous angiographic
embolization.
Competing interests
The authors declare that they have no competing interests.
Authors’ contribution
PP conceived the study, gathered and analysed the data, and drafted the
manuscript. POB conceived the study, analysed the data, and drafted the
manuscript. HL analysed the radiological data and drafted the manuscript.
MÖ conceived the study, analysed the data, supervised the conduct of the
study, drafted the manuscript, and takes responsibility for the article as a
whole. All authors have read and approved the final manuscript.
Acknowledgements
Prehospital data was acquired by R.N. Hans Grubb, Emergency Medical
Services, Umeå University Hospital. The statistics calculations were performed
with the aid of Senior Lecturer Johan Svensson, Umeå School of Business
and Economics; Statistics, Umeå University.
Author details
1
Department of Anaesthesiology and Intensive Care, Sunderby Hospital,
SE-971 80 Lulea, Sweden. 2Department of Surgical and Perioperative Sciences;
Surgery, Umea University, SE-901 85 Umea, Sweden. 3Department of Radiology,
Umea University, SE-901 85 Umea, Sweden.
Received: 22 March 2014 Accepted: 5 August 2014
Published: 15 August 2014
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